Or mailing to PO Box 2078, Sisters, OR 97759 by 2/1/19.Postmarks not accepted.

COVER PAGE: LIMIT TO ONE PAGE

Name of Organization:

Amount of this Request:

Project Name:

Project Description in one Sentence:

Year Organization Incorporated:

Chief Executive Name and Title:

Contact Name and Title (if different):

Contact email address:

Website:

Phone:

Address:

Geographic Area Served:

Timeframe in which funds will be used:

Total Project Cost:

This request is what % of Total Project Cost:

Fiscal Year:

Expenditure Total Last Year:

Expenditure Total expected this Fiscal Year:

Revenue Total for last year:

Revenue Total expected this fiscal year:

Please list the 5 single largest revenue sources/contributors and amounts for this fiscal year or last fiscal year. Individuals may be listed as anonymous.

NARRATIVE:LIMIT TO 2 PAGES

1. One paragraph summarizing your proposal

2. Mission Statement

3. Organizational background:Describe the organization’s qualifications, history of success and use of volunteers.If this project is a collaboration, please describe the other organizations involved and identify the lead agency.

4. Needs Statement:Describe the needs that will be addressed through this project.Explain how the need was identified.

5. Project:Please include the following:

Who will be served?

How will the project meet the needs identified?Include goals, activities and timelines.

What is the anticipated impact and how will you measure effectiveness?

Please list other funding sources for this project and note if funding is secured.

File Attachments:

Attach the following files: (Sending attachments in more than one email is acceptable.)